TFP, PLLC | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Gender

My relationship to the patient

Myself Spouse Parent Child Other Relative Friend or Acquaintance Other

Administrative

How were you referred to this practice?

Clinician (please specify name of clinician in "More details about Referral Source") Psychology Today Google Other (please specify in "More details about Referral Source")

More details about Referral Source

e.g., Name of referring clinician, Name of other referral source

Client Preferences

What is your preferred appointment location?

In-person at West Chester, PA office (Tuesday - Friday) In-person at Greenville, DE office (Monday) Virtual visit in which I will be located in PA, DE, or NY

Are there any times that would NOT work for scheduling an appointment?

Please note that Dr. John's office hours are weekdays from 6am to 3pm.

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Do you have any other scheduling limitations?

Limited to 600 characters

After you submit this form, Dr. John will contact you via a brief phone call to discuss appointment booking. Please leave times which would be convenient to reach you, and the best phone number for those times.

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Billing & Payment

HEATHER JOHN, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible.

Yes No

Dr. John is not a Medicare provider. If you are a Medicare beneficiary (regardless of whether Medicare is your primary payer or your secondary payer), you would need to sign a private contract with Dr. John, agreeing that you are fully responsible for all payments to this practice, and that you agree to not submit claims for payment to Medicare (including supplemental Medigap). Please indicate whether you do, or do not, have Medicare, and whether you expect this status to change within the next 12 months.

I do have Medicare. I do NOT have Medicare, and I do NOT expect this status to change within the next 12 months. I do NOT have Medicare, but I DO expect this status to change within the next 12 months.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.